Provider perceptions of pharmacists providing mental health medication-related support in patient-centered medical homes

Abstract

Objectives

This study’s objectives were to identify primary care providers’ (PCP) comfort level, potential barriers to management of patients with mental health disorders, and attitudes around clinical pharmacist-provided mental health medication-related support.

Methods

A 16-item, cross-sectional survey was completed by PCPs in 14 patient-centered medical homes (PCMHs) at one academic medical center. Items assessed include PCPs’ perceptions of the proportion of patients with a mental health condition, access to psychiatry services, confidence in mental health condition management, clinical pharmacist-provided mental health medication support, and demographics. Checklist, Likert-scaled agreement statements, and an open-ended question to assess barriers managing mental health medications were included. Descriptive statistics and qualitative content analysis were used.

Results

Respondents (n=85) included attending physicians (67.1%), resident physicians (24.7%), and advanced practice providers (8.2%). The average number of years in practice was 11 (SD 8.6). The majority perceived that 26-50% of their patients had a psychiatric illness (57.7%), referred < 10% of their patients (67.1%) to psychiatry services, and timely access to psychiatric services was not acceptable (87.0%). Participants felt confident diagnosing a patient with depression (97.6%) and starting antidepressants (94.1%) compared to antipsychotics (11.7%) or mood stabilizers (7.1%). Participants agreed that having the clinical pharmacist in clinic to provide support regarding psychiatric medications would increase their comfort level (M 4.0 (SD 1.04); increase in comfort level by provider type was not different (p=0.20). Emerging barriers were lack of knowledge or training; low comfort in diagnosing severe psychiatric conditions; and access to psychiatry services.

Conclusion

Outside of the diagnosis and treatment of depression, PCPs indicate a lack of comfort in treating PCMH patients with mental health disorders. Pharmacists can play a key role by providing mental health medication management support to improve access and address PCMH patient’s mental health needs.

Background

Approximately one in five people in the United States (US) has a mental health condition during their lifetime and patients with mental health conditions have a mortality rate approximately 2.2 times higher than the general population.^1,2 It is estimated that 68% of adults with a mental health condition also have one or more chronic physical conditions.³ However, out of the approximately 44.7 million US adults with any mental health condition in 2016, only 43% received treatment.¹ After adjusting for population growth, one study indicated a 10% decrease over the last decade in the number of practicing US psychiatrists and a small increase in the number of primary care providers thus adding to the shortage of mental health professionals.⁴ Co-occurring patient physical and mental health needs and this potential decline in access to psychiatry services provide the primary care setting or patient-centered medical home (PCMH) with the prime opportunity to address both patient needs in one place.

Indeed, the National Committee for Quality Assurance (NCQA), one of the recognition bodies for PCMHs, has proposed that PCMH standards emphasize the incorporation of team-based care and behavioral health integration into the primary care setting.⁵ Previous studies have explored primary care providers (PCPs) perceptions around treating mental health conditions. Perceived need for education around community resources, behavioral health roles, low perceived access to referred psychiatry services, and payment barriers have been identified.^6-9

Other studies have explored PCPs’ attitudes towards a collaborative approach to addressing mental health conditions in the primary care setting, yet there is a lack of studies involving pharmacists.^9-11 These studies have demonstrated a largely favorable attitude by PCPs towards a collaborative approach to mental health in the primary care setting, including mental health professionals, behavioral specialists, and social workers. Additionally, studies have indicated the impact of clinical pharmacists improving medication management of patients with mental health conditions in the primary care setting.^12-17 Therefore, it is critical to explore PCP’s attitudes toward pharmacist-provided mental health medication support within the PCMH and the needs of PCPs in mental health management in the design of a new pharmacy service.

PCMH pharmacy and psychiatry leadership within our academic medical center are exploring ways to help support the management of patients with mental health conditions, primarily around medication management and education. This descriptive study was part of a needs assessment to inform the design of an ambulatory care PCMH pharmacist service focusing on mental health medication support within the PCMH.

Objectives

The objectives of this study were to identify PCP comfort level, potential barriers to management of patients with mental health conditions, and attitudes around clinical pharmacist provided mental health medication-related support.

Methods

A 16-item cross-sectional survey was developed that assessed PCPs’ perceptions of the percent of patients with a mental health condition (1 item) and percent of patients referred to psychiatry (1 item). A 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) was used to assess provider agreement with statements relating to their perception of time frame acceptability for their patients to access psychiatry services (1 item), self-efficacy in ability to manage mental health conditions (5 items), likelihood to start mental health medications (3 items), and whether a PCMH pharmacist providing mental health medication-related support would increase their comfort level with managing mental health medications (1 item). This comfort level was defined and assessed by the survey question “ I feel that having the clinical pharmacist in my clinic available to provide support regarding psychiatric medications (such as provide education to patients and/or providers, make recommendations, assist with monitoring ) would increase my comfort level with psychiatric medications.” Additional barriers to initiating or managing psychiatric medications were assessed with an open-ended question (1 item). PCPs’ current role, years in practice, and primary PCMH practice site were also collected (1 item each). Answer options for PCP’s current role were attending physician, resident physician, and advanced practice providers. Advanced practice providers included nurse practitioners and physician assistants.

REDCap, a secure, web-based electronic data capture system was used in survey design, administration, data collection, and data management. The survey was informed by a review of the literature^7-11 and clinical pharmacist expertise. The survey was pilot tested with a convenience sample of three PCMH clinical pharmacists and two psychiatrists and then revised for clarity, readability, and content. The survey is provided in Appendix 1.

All PCPs (n=275) at the 14 academic medical center primary care PCMHs were eligible to participate and no exclusion criteria were applied. The clinical pharmacist emailed their PCMH PCPs the REDCap survey link and invited them to participate. No individual identifying information was collected. One reminder e-mail was sent by the clinical pharmacist to increase participation. The timeframe for survey completion was February to May 2017.

Survey responses compiled and analyzed with Stata/SE 14.2 (College Station, Texas). Descriptive statistics (mean (SD), n (%)) were used. Chi-square analysis was conducted to examine if a clinical pharmacist providing mental health medication management support increased PCP’s comfort level with these medications differed by provider type. The a priori significance level was p < 0.05.

Qualitative content analysis was used to identify barriers to managing mental health medications in the PCMH setting. Open-ended responses to the survey question “Are there any other barriers to initiating or managing psychiatric medications not covered in this survey?” were the unit of analysis. Two authors (ABC and JRB) independently coded each answer to identify potential barrier categories. The categorization was inductive and barrier categories were not identified a priori. The preliminary coding of barriers was compared between the two authors in a consensus meeting and categories were collapsed into themes. Discussion and agreement of the final emerging barrier themes occurred.^18,19

Results

A total of 85 primary care providers from 14 PCMHs completed the survey. The survey response rate was 32%. The majority were attending physicians (67.1%) and an additional 24.7% were resident physicians and 8.2% were advanced practice providers. The average number of years in practice was 11 (SD 8.6, range 1-31).

Over half of participants (n=49, 57.7%) perceived that 26 to 50% of their patients have a psychiatric illness including anxiety, bipolar disorder, depression, or psychotic disorder and less than 10% refer their patients with a psychiatric condition to psychiatry (n=57, 67.1%). The majority of participants disagreed that their referred patient would been seen by psychiatry in a reasonable time frame (n=74, 87.0%). Participants’ responses to survey items related to selfefficacy in management of mental health conditions, likelihood to start mental health medications, and having the clinical pharmacist in their clinic available to provide support regarding psychiatric medications are summarized in Table 1.

Table 1.

Primary Care Providers Perceptions of Management of Mental Health Conditions and Likelihood to Start Medications (n=85)^a

Self-efficacy related to management of mental health conditions	Mean (SD),Range
I am confident in my ability to:	N (%)
Diagnose a patient with depression.	4.6 (0.58), 2-5
Strongly Disagree	-
Disagree	1 (1.2)
Neither Agree nor Disagree	1 (1.2)
Agree	28 (32.9)
Strongly Agree	55 (64.7)
Diagnose a patient with a more severe psychiatric illness (e.g., psychotic disorders, bipolar disorder). (n=84)	3.2 (0.96), 1-5
Strongly Disagree	2 (2.4)
Disagree	21 (25.0)
Neither Agree nor Disagree	21 (25.0)
Agree	36 (42.9)
Strongly Agree	4 (4.8)
Recognize signs and symptoms of suicidality in a patient. (n=83)	4.2 (0.61), 2-5
Strongly Disagree	-
Disagree	1 (1.2)
Neither Agree nor Disagree	5 (6.0)
Agree	52 (62.7)
Strongly Agree	25 (30.1)
Adjust a patient's psychiatric medications. (n=84)	3.7 (0.74), 2-5
Strongly Disagree	-
Disagree	7 (8.3)
Neither Agree nor Disagree	21 (25.0)
Agree	50 (59.5)
Strongly Agree	6 (7.1)
Appropriately monitor a patient on psychiatric medications (i.e., side effects and/or metabolic effects). (n=84)	3.6 (0.71), 2-5
Strongly Disagree	-
Disagree	6 (7.1)
Neither Agree nor Disagree	26 (31.0)
Agree	47 (56.0)
Strongly Agree	5 (6.0)
Likelihood to start mental health medications I am likely to:
Start an antidepressant medication in a patient recently diagnosed with depression.	4.6 (0.70), 1-5
Strongly Disagree	1 (1.2)
Disagree	-
Neither Agree nor Disagree	4 (4.7)
Agree	25 (29.4)
Strongly Agree	55 (64.7)
Start an antipsychotic (typical or atypical) medication in a patient presenting with symptoms of a more severe psychiatric illness.	2.1 (1.06), 1-5
Strongly Disagree	27 (31.8)
Disagree	40 (47.1)
Neither Agree nor Disagree	8 (9.4)
Agree	6 (7.1)
Strongly Agree	4 (4.7)
Start a mood-stabilizer medication (e.g. lithium, valproic acid) in a patient presenting with symptoms of bipolar disorder.	2.0 (0.96), 1-5
Strongly Disagree	31 (36.5)
Disagree	35 (41.2)
Neither Agree nor Disagree	13 (15.3)
Agree	4 (4.7)
Strongly Agree	2 (2.4)
Clinical pharmacist support and comfort level
I feel that having the clinical pharmacist in my clinic available to provide support regarding psychiatric medications (such as provide education to patients and/or providers, make recommendations, assist with monitoring) would increase my comfort level with psychiatric medications.	4.0 (1.04), 1-5
Strongly Disagree	3 (3.5)
Disagree	4 (4.7)
Neither Agree nor Disagree	17 (20.0)
Agree	30 (35.3)
Strongly Agre	31 (36.5)

^aLikert-scale: 1 = Strongly Disagree to 5 = Strongly Agree

Participants felt confident diagnosing a patient with depression (97.6%) and agreed with their likelihood to start an antidepressant in patients recently diagnosed with depression (94.1%). PCPs disagreed with their likelihood to start an antipsychotic or mood-stabilizer medication in patients with more severe mental health condition or bipolar disorder (78.9% and 77.7%). Participants agreed that having the clinical pharmacist in their clinic available to provide support regarding psychiatric medications would increase their comfort level with these medications (71.8%). This increase in comfort level did not differ by attending physician, resident physician, or advanced practice provider type (p = 0.20).

A total of 35 responses were received to the open-ended question “Are there any other barriers to initiating or managing psychiatric medications not covered in this survey?” Three main themes emerged related to providers’ perceived barriers to managing mental health medications in the PCMH setting: perceived lack of knowledge or training, low confidence in diagnosing severe mental health conditions, and lack of timely access to psychiatry services, if needed.

Discussion

Overall, this study found that PCPs within this academic medical center’s PCMH primary care clinics agreed that having a clinical pharmacist within their clinic to provide mental health medication support would increase their comfort level with mental health medication management. This may be more important around support in the use of antipsychotics and mood-stabilizers as providers reported lower likelihood to start these medications.

Pharmacist competence and confidence in recommending and monitoring mental health medications should be assessed prior to implementing mental health medication management within the PCMH. A 2015 survey by McKee and colleagues highlights mood stabilizer knowledge as a deficit among pharmacists.²⁰ A recent study indicated that pharmacists felt less comfortable delivering patient counseling for mental-health related medications when compared with cardiac medications.²¹ To increase their comfort level with psychiatric illnesses, PCMH-based pharmacists could consider shadowing psychiatric pharmacists, attending continuing education on psychiatry focused topics, or even attending psychiatry-focused meetings to stay up-to-date and informed.

As the need for mental health services continues to rise, the role for PCMH-based pharmacists involvement in management of these disease states will continue to increase. In PCMH settings, these needed services may include medication selection and dose adjustment, monitoring for medication efficacy and adverse effects, appropriate laboratory monitoring and use of validated instruments (e.g., Patient Health Questionnaire (PHQ)-9), providing patient education, and seeking collaborative practice agreements (CPAs) around the treatment of these disease states. A CPA is a formal agreement between a pharmacist and a prescriber that defines authorized delegated patient care functions that a pharmacist can perform. The scope of delegated functions may be limited by the pharmacist’s state practice laws. The extent of CPA developed may also vary depending on the training and comfort level of the pharmacist.^22-24 PCMH primary care pharmacists may elect to model their CPA after successful psychiatric-pharmacist medication management services within the primary care safety-net setting or primary care mental health integration services in Veterans Affairs medical centers.^14-16

The barriers identified by PCPs in this study may also be perceived by PCMH pharmacists as well; namely, confidence and lack of training, as previously discussed, and perhaps lack of access to a psychiatry specialist. At the authors’ institution, where ambulatory care pharmacists are embedded in every PCMH clinic, we also have two post-graduate year 2 (PGY2) trained psychiatric pharmacists available for consultation. Additionally, to increase PCMH pharmacist’s comfort level with mental health medication management support, targeted educational resources were developed and delivered to review topics such as depression and anxiety. An outpatient psychiatric longitudinal learning experience was also implemented for PGY2 ambulatory care residents.²⁵ However, these resources may not be readily available at other institutions. In order to support PCMH pharmacists in filling this gap, considerations must be made for adequate training and support as well as access to a psychiatric pharmacist to successfully meet this need. Currently, there are over 70 PGY2 American Society of Health- System Pharmacist-accredited PGY2 psychiatric pharmacy residency training programs and over 1,100 pharmacists designated as Board Certified Psychiatric Pharmacists (BCPP).^26,27 As PCPs rely on psychiatry providers, ambulatory care pharmacists may rely on PGY2 trained/BCPP psychiatric pharmacists, whose value as part of the medical team has been established.²⁸

This survey also highlights the demand for mental health services at our institution exceeds the capacity. Access continues to be a challenge despite recent initiatives focused on addressing this very issue (e.g., initiating a new evaluation clinic as well as piloting behavioral health collaborative care within the PCMH). There continues to be a role for professional pharmacy organizations to advocate for the expansion of and reimbursement of pharmacist-provided mental health medication management to improve patient access to timely health care. PCMH pharmacists are in a unique position given their availability in primary care clinics and accessibility to patients which provides an opportunity to better meet their patients’ mental health medication needs. However, for pharmacists to help address PCMH patients’ mental health needs, reorganization of pharmacists’ medication and disease state management services from other chronic conditions to mental health conditions (e.g., from diabetes to depression) or expansion of the number of pharmacists practicing within the PCMH should be considered.

Limitations

This study was conducted in one academic medical center’s primary care PCMHs which limits generalizability. Additional limitations include this study’s low response rate and use of a non-validated survey instrument. There is also a risk that these PCPs may have had previous interactions with psychiatric pharmacists which would have influenced their response, potentially both positively or negatively. Social desirability bias is a concern as the survey recruitment emails were sent by the PCMH pharmacist to increase participation. However, the information gained was used to assess our provider’s needs and perception of clinical pharmacists helping to support mental health medication management within our PCMHs. In turn, the results were used by PCMH pharmacy leadership to support the design and role of pharmacist mental health medication management pilot services. Future research is warranted to evaluate ongoing mental health medication management needs, service development and expansion, and the impact of pharmacists supporting mental health medication management on patient outcomes and provider satisfaction within primary care.

Conclusion

Expanded roles for PCMH pharmacists to provide mental health medication management support for patients with mental health conditions is warranted. Given the demand for mental health care in the PCMH setting, pharmacist training should focus on the ability to offer this needed and valued service to care for the mental health needs of their patients. Pharmacists may focus on supporting providers by offering consultation on medication selection and medication management, adverse effect and efficacy monitoring, patient education, collaborating with psychiatric pharmacists, and seeking opportunities for collaborative practices that may allow for taking greater ownership in meeting the mental health medication needs of their patient population.

Primary Care Providers Management of Mental Health Treatment Survey